Anal Atresia: Felony

The morning came just as early as every other morning seems to in Haiti.  The sun is not yet up.  Joel is clanking buckets down to the canal to fetch some water.  Goats, roosters, and dogs are all in the midst of some hot debate #OldMacDonaldNeverSlept.  See post 'Insomnia' and then know that the previous night's sleep was pretty bad.  Maybe I subconsciously knew I would be falsifying government documents, committing identity fraud, and bribing public officials that day.

John was coming early in the morning so we could go back to Port au Prince.  It had to be done.  And it may have to be done daily until I leave so we can progress towards this passport and medical VISA.  "I can.  I will. I must.  Regardless of the odds, get the job done" #BigAlQuotes.  He showed up a little after 8 am.  I had time to get my surveying team off in the right direction with the hope that they'd be able to continue my work.  I miss having productive interviews with people.  John and I walked out of the compound and hailed a pair of motos.  After waiting for twenty minutes for the mother, father, and girl of the hour we were finally PAP bound.

Since I had just completed this leg the day prior I had a good feel for how everything would go.  We'd take a tap tap from St. Medard to Cabaret.  We'd switch until we got to someplace in PAP.  Then we'd switch to take a tap tap to Crois des Bouquets or some other town and then one to CDB depending on what we found.  Piece of cake right?  There are no maps.  The only information you have to go by are the dudes waving people into the tap tap and repeating the destination.  They all have their own timing and rhythm.  Picture them like the 'stadium beer men' of the transportation world.

There wasn't a lot of traffic this early in the morning.  Most of the shuttles were large buses, which John informed me were going to a different station in PAP than we needed to go to.  Not sure how he knew or if that information was accurate, but I assumed that to be true.  It isn't a very easy to navigate system.  The first tap tap to Cabaret filled up quickly, but the driver and the herder saw I was white and immediately found room for the 4 of us.  Mom, dad and baby sat shotty with the driver.  John and I had the luxury of sitting on top of the tap tap.

Was it safe?  No.  Is riding in a tap tap safe?  No.  If I'm going down in a blazing tap tap crash then I at least want to be able to see things transpire.  And who knows, maybe I would be better off flying away from the crash instead of being smashed inside.  Another revelation.  Is it just me or would the 'Tap Tap' 4D ride at Universal Studios be the best ride that gave everyone a migraine headache?  Imagine if you will.  You're sitting on a rock hard, wooden bench.  You have fifteen other, sweaty bodies crammed up against you.  The terrible Haitian rap music is blaring over the sub-woofer such that you cannot hear yourself think.  The driver swerves and slams on his breaks seemingly at random in order to keep people guessing.  And for good measure you get blasted with a horn or a face full of exhaust every now and then.  Super realistic.  Definitely an adventure.  And think if they made video games where you were the tap tap driver having to pick up fares and dodge traffic.  How popular would that be!?  #Awesome

FWIW riding on the top of the tap tap may be the best idea I've had this entire trip.  You have leg room.  You have fresh air.  And other than the fact that you have a great view of every close call on your way you can relax up there and enjoy the wind whipping through your hair.  And you get to see all sorts of sights that make you understand why trauma is so common.

We arrive at Cabaret.  We arrive at Chada, which apparently is the center of PAP (Who knew?).  And then I find us a comfy tap tap ride to Crois des Bouquets.  One problem.  I don't recognize any of the buildings where they dropped us off at.  Our previous trip we had to take two tap taps from Chada to CDB, but this time we found a straight shot.  Apparently that straight shot ended somewhere other than the street we were on the day before.  John asked for directions. "La" was the response.  "La" can mean 'here', 'there', 'down there', far away or close to you.  It is quite possibly the least helpful word in the language.  But it's still the one everyone uses accompanied by a lot of gesturing.

I get smart.  I bust out my GPS device that I have been using to mark landmarks throughout my trip.  Money.  It leads us right to the back alley.  It's after 11 o'clock.  We left Mission Matana over two hours ago.

The same man came over as soon as he saw us. I introduced the father to him and we made the necessary donations to expedite the filing process.  The husband got his back alley blood test and we were back in business.  I had John ask the man if he knew of where we could get a photo to turn this into a photo ID.  You bet he did.  He took us across a side street and back around some store fronts to a "Photo Digitale" shop hidden behind them.  I'd need photos for each parent and if possible a passport photo for the baby.  Thirty dollars Haitian per person and they'd give me six headshots of each.  Sounds like overkill, but I'll take it.

Time kept moving and we kept sitting.  The photos were taking forever.  At some point I thought that the store was some front for a human trafficking enterprise and my family was in the back of a truck somewhere.  In our down time I made John help me shop some of the local pharmacies.  We need some anti-scabies cream and some stain for our microscope slides.  You'd think we were wanting to buy chemo.  Nobody had heard of the stuff we were asking for.  But, if you need a benzodiazepine or hard core antibiotics like chloramphenicol then you're in luck #SafetyFirst.

It's creeping past noon.  The family finally emerges and I pay for the pictures.  My inside man grabs one each of the male and female to get everything "plastinated".  I tell John to find us some food as I'm sure the family is getting hungry.  They probably didn't eat breakfast and I would be surprised if my translator did.  We find a tent cooking up some rice with sauce and grab a seat.  My stomach yells at me as I agree to buy a plate for myself.  It tastes good.  Let's hope I don't pay for it later.

After we finish our meal I find Samuel, our insider, and he hands over an awesomely bootlegged photo ID for the mom.  Even has a NIF number which I can only assume is the Haitian equivalent of the social security number.  But now we wait for the father's ID.

It's about 1:30 now.  John had said that we needed to meet his cousin by 2:30 if we wanted to get the Archived Birth Certificate today.  And by Archived Birth Certificate I mean whatever these people think is the Archived Birth Certificate because I haven't found any consistency when it comes to describing it.

I pull the trigger.  "John, I need to you go get the process started on the Archived Birth Certificate.  I'll wait here until the other ID gets made and then meet you in Chada."  He didn't want to.  And I didn't really want to put that kind of responsibility on him.  He tends to fold like a lawn chair.  But we can't keep making trip after trip to PAP.  My psyche can't take it #Exhausting.  He goes.  I'm translator-less.  Minutes tick away into hours and I haven't seen Samuel.  I pace.  The sun is beating down.  The family is tucked away in the shade by the back alley blood test shop.  I decide to roll up my sleeves and work on my tan #StillPasty.

It's almost four o'clock.  I call John.  He said he started the process and it'll only cost us like $400 Haitian dollars.  He paid in advance.  Of course he did...  I tell him to wait at Chada for us.  We'll figure out how to get there.


Finally Samuel emerges with the photo ID for the dad.  Don't pay attention to the fact that the photo is skewed or that over half of the lines aren't filled out. I'm sure hoping that all the government officials I'll be talking to don't pay attention to that either.

We left Crois de Bouquets.  We hopped in a tap tap and clunked along another crappy road.  My abductors have never gotten the kind of workout as when I've been fighting for every centimeter of leg room.  It's a battle and I'm totally unprepared.  I always assumed that everyone was as squished as me in the back of the tap tap.  It wasn't until a fortuitous near miss caused the tap tap driver to slam on the breaks.  All of a sudden the six, skinny older ladies sitting to my left went sliding towards the front of the tap tap.  I found myself with an extra six inches of butt room on the bench.  Those sly old ladies.  Holding out on me this whole time.

Police gathering outside the government building

We made it to Chada and found John.  He informs me that we need to come back Monday with a medical paper saying she needs the surgery so they can move quicker.  Great.  The tap tap ride back to Cabaret was uneventful.  I was sitting next to a young boy so I opted to share my head phones.  He loved it so much he asked if he could have it #Standard.

For the last leg of the ride John and I opted to sit on top of the tap tap again.  I needed some space.  The back to back grind of traveling all the way to PAP was wearing on me.  And coupled with the frustrations I had with John's inability to cost control.  He may be the only Haitian who will end up paying more for a good or service than me.  I joked with Mike that someone could sell him a $5 bill for $20.  The streets of Haiti are filled with hustlers and John, unfortunately, makes for an easy mark.

I give the mom and dad 30 Gourdes to pay for their moto ride back home while John and I head back to the compound.  My surveyors have also returned.  They look as tired as I feel.  It's pay day for everyone and everyone has worked hard for me.  And with all of my surveys I've come to the conclusion that the Puritan work ethic is not inherent to their culture.  I've been lucky that God has led me to these kids.  They're effort is worth every penny that I've paid, and probably more.  The day is done.  Work is finished for now.  I will start again on Monday by returning to PAP.  I don't know where I have to go and I don't know what I'll have to do, but I do know that God will provide guidance.

Trauma

So, I got hit by a car today.  And I've been wanting to write a blog about trauma in Haiti for the longest time because it is so common.  I just didn't know it would take me being the one 'trauma'tized to actually getting around to writing it #FunWithWords.  I'm fine, for those who were concerned about my well-being.  For those that weren't... I would like to express my disapproval with words that my mother will not approve of.  #NotMadImDisappointed.  The whole "me getting hit by a tap tap" story isn't the one I'm going to talk about.  But, I had this patient...

He was an older gentleman that was chilling under a shade hut fashioned at an intersection where people can sit, watch traffic, play dominoes, sell d'lau, or whatever they want.  I was doing the survey thing and trying to find an occupied house for my pen to point to #WhenRandomizationIsntRandom.  Like most people, this gentleman mistook me for a doctor and asked to speak with me.  Not a problem.  I like standing still under the hot sun #Sarcasm.  He awkwardly maneuvers his arms and cane around, gesturing to me, that something was going on with something above his waist.  It wasn't very clear.  So I got the translation.

"He's complaining about pain in his shoulder."  Me too buddy.  Can't shake it #HillsachsLesions.  "How long has it been going on?"  I ask.  "He thinks thirty years."  Uh huh.  I'm gonna go out on a limb and say that I can't fix this problem today.  Again, he's trying to move his arm and can't.  My powers of observation combined with my inability to keep my mouth shut force me to ask the question, "Did something hit your arm a long time ago, like a car collision, moto wreck, the ground from a fall?"  Even looking at his arm I could tell that the anatomy wasn't appropriate.  Something was amiss.  "I got hit with a machete."

Damn.  And he did too.  His scar extended from the middle of his back, over his shoulder, towards the front of his chest (as you can see).  This scar was well-healed.  His shoulder joint was destroyed.  I moved his wrist and could feel the grinding with my other hand.  This man had dealt with a massive blow with a machete, somehow survived surefire exsanguination, and then dealt with a non-functioning dominant shoulder for much of his adult life.  #WhatDidHeDoToProvokeTheAttack  I really wanted to ask the story behind the assault, but unlike most of the time I've been down here I held my tongue.

I had him come to one of our morning clinics and Angie loaded him up with Tylenol and Ibuprofen.  Unbeknownst to me at the time of meeting him, he was from the mountains.  He had walked five hours the morning of clinic to get there.  He moved about six inches with each step.  We gave him money for a moto, but the last time we saw him he was plugging his way up the hill on his own two feet.

While violence is certainly something to be concerned about in Haiti, I would think it pales in comparison to the number of trauma patients generated by their crazy transportation system.  Although, I did see a guy get his face cut with a knife at the market last Wednesday #Carazy #WasItWorthTheExtraFiveGourdes?

We've had a few patients come in that were victims of moto accidents.  The first CHW patient was a little boy who suffered a burn on most of his lower leg at the hands of a moto exhaust.  A couple weeks ago we had a mother and father bring in a little girl who had had the moto fall over on its side while she was sitting on it.  She landed on her wrist and the moto landed on her leg.  Without imaging we couldn't diagnose much.  But everything seemed structurally in tact.  Unfortunately for us, it was the middle of the week so we couldn't send her to one hospital that only had xray on Monday and Friday and the Health Center downtown's xray machine was broken.  We didn't even have an ultrasound to work with.  So I fashioned a rudimentary splint for her wrist to hopefully prevent avascular necrosis.  And then I fashioned an even crappier splint for her lower leg just to give her some support.


Come to find out, the father was the driver of the moto and he hurt himself too.  His leg wasn't spared.  Everything looked fine and we gave them both some tylenol.  The next day we sent the CHWs to check on her.  Apparently the parents thought deep-tissue massage of her lower extremity would help her heal...She was in agony.  We decided to use some of our casting supplies to make sure that didn't happen again.  Now I just need to find some cast cutters to get the damn thing off...And now her dad is super psyched to drive me if I need a moto ride #FriendsWithBenefits.


And as luck would have it there was a moto accident that occurred within the hour that I returned from Port au Prince from dropping Angie off at the airport.  Mike and Chris weren't set to arrive till the next day.  We had given the translators the day off.  And I was all alone at Mission Matana.  So why wouldn't there be a moto wreck?



It looked nasty.  The young male had fallen off the back of the moto as it was cruising down the road.  Some of his skin felt compelled to stay on the ground.  The rocks that help "hold the road together" thought it nice to give him something to remember them by.

His left leg was covered with superficial scrapes.  His right shin had a deep gash exposing some tissue beneath the skin.  His right ankle and foot didn't have much skin over it and somehow he'd received a thick cut slicing over the bony landmark.  #GottaCoverBasics #ABCs #CSpine.

I tell the girls living at the compound with me to grab a lot of d'lau.  This is gonna take a while.  I start cleaning and while I'm doing so (without anything more than tylenol for pain btw) I'm trying to convince him to just go to the hospital where he can be checked out by someone with more equipment.  He wasn't having it.  I irrigated #IfOnlyTheFieldsWereAsWellIrrigated #MountainsBeyondDeserts.  Everything was dirty.  I was convinced I was looking at bone mainly because I'm paranoid.  I was nowhere near bone.  Two of the cuts were gonna need to be closed with suture.  I numbed him up and then bandaged the other minor scrapes before stitching.  It's been a while.  I won't lie.  But it came together nicely.  And, surprisingly enough, he has come back for his dressing changes every two days like we asked.  He may be one of five patients who come back for follow up like requested.  His wound is healing very nicely.

Trauma pervades the culture in Haiti.  Jobs are risky.  Safety precautions are minimal.  Equipment is on its last leg.  Traffic is horrendous.  Night is pitch black.  And violence pervades a culture teeming with voodoo priests, uneducated adolescents who idolize the hip hop culture, and former militants.  Nobody seems to be spared.  I've spoken with an evangelical group who has been doing missions in Haiti since the 80's.  The gentleman I spent most of my time talking with has more stories than the Bible.  Fortunately he's still alive to tell them.  Too many of his stories included, "and then there was a gun in my face" or "I hope you're prepared to die tonight."

While I have not had an experience quite like these I have encountered some resistance to my being here.  Some people don't trust my intentions.  Some people think I'm objectifying them.  Some people want me to leave.  And encountering an apple of this sort can really spoil your taste for apples of all kind #WonderIfHaitiansWouldResentBeingReferredToAsApples.  Haiti comes with some extreme highs and extreme lows to say the least.  Some days it's hard to find the energy to get up and get to work, but somewhere out there is an apple that is ready to be tended to.

Anal Atresia: The Need for Number 2

Surveys have been cast aside.  Meet and greets have been postponed.  Town hall meetings, well there was never a repeat scheduled after the disaster of the first one.  But, regardless, they would have had to be canceled.  My new job is to get our patient the surgery to correct her anal atresia.  This won't be easy.

Haiti is a country where (at least by my "data") >80 % of births occur in the home.  If you look past ten years ago I would guess that number is safely over 90 %.  That means a lot of things.  Maternal and infant mortality are higher.  Not because midwives aren't trained well enough.  Most of the time the delivery drives it self.  Even med students can perform an uncomplicated delivery.  But when things go wrong it's very difficult to get the patients to a hospital quickly.  That's not what this post is about.  Everyone can pretty much assume that maternal and infant mortality will be higher as a result of home births.  An under-recognized complication of this is that there is no record of births.

Birth certificates are scarce in such a setting #Obvious.  After all, why would a family go get a birth certificate made?  It costs money and doesn't provide them with any real benefits.  Or, better yet, they get it made and then because of the living conditions and drastic weather the papers quickly become shreds.  This makes my job seem impossible.  When we inquired as to what it would take in order to get Begeka a medical VISA our response looked like this:

- Photos of the affected area #Creepy #Pervert #EasyToDo
- Birth Certificate of Child
- Archived Birth Certificate #WhatsTheDifference #NobodyKnows
- Birth Certificate of Each Parent #DoTheyEvenKnowTheirOwnBirthday
- Photo ID of Each parent #NickPapageorgioFromYuma
- Pre-Op Labs on Child: Malaria, HIV, H/H, ABO Compatibility
- Imaging needed by surgeons #CanIUploadToEPIC
- Letter from Haitian doc saying surgery can't be done in Haiti #MaybeALie
- Letter from Haitian doc saying patient is safe to travel
- Get Passport of Child
- Medical Power of Attorney signed over the host family
- Pay for VISA at a Bank
- Fill out online VISA form
- Have our org write a letter to embassy with our request and establishing me as the local contact
- BTW all documents will probably need to be in French and English

LOL

SMH

FML

Fortunately the family was able to get a birth certificate for the child and the father still had his from when they got married.  Two down, one to go.  There is an office in Arcahaie that we visited.  The cost for a hand-written "birth certificate" for an adult with no previous documentation: $300 Haitian.  The country is literally saying, "We will give you an identity and it'll only cost you a month's salary."  Three hundred Haitian dollars is roughly 35-40 US dollars.  The cost is cheaper the younger the person.  Again, these are hand-written right in front of you.  Gotta be legit, right?

I skipped over the Archived Birth Certificate because it appears that nobody really knows what that is.  I've been told by a group that has gone through this process before that it is a typed birth certificate copy  produced at some central office in Port au Prince.  After some pre-determined amount of time, all of the branch "birth certificate makers" bring their books to PAP where someone enters them into the computer #GladToSeeThereIsAPaperTrail  #WillSomeoneTeachThemGoogleDocs.  But I have yet to find a Haitian involved in the case who knows where to go or what it will take to get the document.

The pre-op labs should be easy enough right?  There is a state hospital just down the road from us!  So we went.  "Can we get an HIV test, malaria test, CBC, Chem 7, and a blood typing?"  "We can only do HIV and malaria."  "You can't give me a cell count?"  "Oh, yes, a 'hemogram'?  We can do that!"  "Yeah, and if you wouldn't mind counting those 'other' cells on the smear that would be great too..."  No blood typing.  No Chem 7 (even after describing what that entailed).  "That'll be $100 Haitian."  #ChaChing

So we went to Port au Prince.  A white guy with eroding patience, a timid translator who doesn't think on his feet, a quiet and slow-walking mother, a two-month-old without a butthole, and three birth certificates loaded up into a tap tap... with about twenty other people.  Dad was working and unreachable #NotHelpful.      At least I was able to purchase some street food for all of us before we departed.  #ProbablyGonnaRegretThatOne  #FeelSorryForMike

My aforementioned translator decided it would be best to get in a tap tap that would only go half-way to Port au Prince.  Guess he thought I could use a Chinese fire drill to stretch out my legs and get some Vitamin D.  Didn't foresee almost leaving the mother and baby in the back of a tap tap on its way back to Arcahaie.  Another crowd fills up around us #GetCozy.  At least I got to spend some time spelling the mother with holding the baby #WhiteGuy+HaitianBaby=Hilarious  #Apparently.

We finally get to Port au Prince.  I still haven't figured out the payment system for the tap taps.  Sometimes I feel like I get more change than the money I gave them.  I just hand them a bill and take solace in the fact that I just traveled miles for pennies where it would have cost me $20 to cross St. Louis in a taxi  #RipOff #TapTapsToBusch.  John then informs me that we need to take another tap tap.  Which in turn leads to another tap tap.  And finally a third tap tap that takes us in the general vicinity of our presumed destination, Croix-de-Bouquets.  #NotLikingThisPattern  Funny thing is, I had developed enough small bills where I would give them like $3 Haitian when we got out.  They rarely question it  #MathSkills  #BusinessAntiSavvy

We head to the municipal office that I hoped would hold the solutions to the Photo ID problem.  It didn't.  They directed us down the street to another office.  Manageable.  No tap taps to take this time.  We walk.  I cradle the baby in my arms.  She's swaddled like she's an Eskimo baby.  I don't think I need to remind people that it's hot in Haiti and this was the middle of the day #FirstTimeMotherProblems.  Again, white guy holding a Haitian baby prompts more than the usual amount of cat calls from the observers.  Not sure what I was saying "Wi" to, but they were getting a kick out of it.





John stalls.  No idea where we are or where we are going.  John, you just were in the office talking to the people about where we needed to go!  #CanIGetABobbyKnightChairThrowInHereSomewhere  I push him forward.  Finally I see what looks to be a government building.  Acronym matches what they told us.  #Success.  Line.  #Fail.  It's about 2 o'clock at this point.  We left the compound well before noon.  Time flies when you're crammed in the back of a tap tap listening to bad Haitian rap.  I tell John to find out what service they provide here.  He stands around.  WOULD YOU PLEASE TALK TO SOMEBODY?  He talks to a pair of adolescents who clearly have no authority on the grounds.  #YoureKillingMeSmalls  I "encourage" him to find some people who look a little more official.  He talks to the guard at the front door #StepInTheRightDirection.

Then we get approached by a man in a yellow button down and khaki pants #WhatsCuriousGeorgeLikeInRealLife?  He motions for us to follow him and he leads us back to the streets away from the government office.  We dodge a couple motos and cross to the opposite side.  He moves quickly, but not far.  Located almost directly across from the government building he ducks between two buildings where a woman waits in a little phone booth sized shack.  He explains that he can make the ID for us here for much cheaper than they'd ask us for inside.  That. Just. Happened.  Considering I had already had internal discussions about downloading a computer program to do the same thing, claiming the father to be deceased, or having John pose as the father for documentation purposes this actually seemed more legit.

Seventy dollars.  That's what the man asked.  Whatever.  Cheaper than the prices I had been quoted and at this point I'd take a Polaroid with her name Sharpe'ed at the bottom.  His female assistant dons some gloves and reaches into a box labeled as 'lancets'.  "Whoa, John, why do they need to take blood?"  He asked.  He got an answer.  He clearly didn't understand.  Either he didn't know what I was asking about or he didn't know what the guy said back to him.  This is way too commonplace.  But right now, I don't care.  "That's fine.  Bleed her dry.  If that'll help her get this ID quickly, let's do it."  Didn't really say 'bleed her dry' but you get the point.






I go buy a soda.  I need some reprieve.  I come back and the man is discussing things with John.  He takes the birth certificate - the $300, hand-written, only copy birth certificate - and my $70 Haitian and heads back across the street.  Please, Lord Baby Jesus, make this work.  Then the nurse said that she cost 100 Gourdes for her service.  Fine.

I step inside the "office" and take a glance at bottles sitting on the table.  "Anti-A Antibodies".  Holy Piki!  "Can you test the baby's blood?"  "Yes, for 100 Gourdes."  Done.  I pull out the lab sheet from the hospital and had her write the results on one of the blanks.  #AlmostOfficial

The man actually returns about fifteen minutes later.  There has been a snafu.  The Director who has to sign all of the documents has left for the day.  I mean, it was 3 o'clock on a Thursday after everyone in the country just had a week off for Karnivale.  Why on Earth would the guy still be at work?  "Can you just give us the card without the signature?"  "No, they won't sign it because they'll think it's fake."  (Well, it is fake...).  And that was that.  We didn't even get to keep the birth certificate.  We literally went all the way to Port au Prince and came back with less than we started with.  I didn't even think that was possible.  Correction, we now know our patient is O+ blood.  And by 'know' I mean that an untrained technician in a back alley told me that she had type O+ blood.  #OnlyInHaiti

So tomorrow my surveys will again be put on hold.  The data we were hoping to gather to give us some direction with community projects will remain stagnant.  I will again ascend into a tap tap surrounded by people that are either scared of me or assume that I'm there to hand out money.  I will switch tap taps at least three times each way.  I will both over and under pay for our transportation.  I will have no idea of where I am.  I will eat food that will likely give me dysentery.  I will drink water out of plastic bags that have never been washed but have been handled by countless people.  Those same bags will then end up on the ground, much to my chagrin.  But through all of this I will be accompanied by an adorable 2 month old girl who still needs to be able to poop.  And hopefully someone can start putting dominoes in place that will fall to form a red carpet leading to a United States operating room.

Cluelessness

Last Sunday Mike and I were invited to attend 'English Club' by some of our translators.  This is a new venture that a few of the men have started within their local community to invoke discussions about various topics as well as practice conversational English.  Seems like a great idea to learn a new language, #CreoleClubAnyone?  Etienne and Wisley told us to show up at 3 pm ready to discuss the environment.  Piece of cake.  There's the sun, trees, dirt, and Al Gore.  What else would we need to talk about?  And I really didn't know what they expected with regards to Mike's and my level of participation.  Are we lecturing?  Are we correcting people's grammar as they talk?  Or are we just going to sit there and have a conversation about polar bears and the ozone layer while they listen?

We go.  And we're fashionably late #WhenInHaiti.  Introductions, a welcoming hymn and a prayer are all done.  All in English.  I can handle Haiti if everyone is going to continue to speak English to me and refer to me by my name.  #NoMoreBlan.  Then comes the topic, "Why men don't have a clue and women always need new shoes."  I laughed to myself.  This just got a little more interesting, and probably insightful for Mike and I.

They play a tape.  I have no idea where they got this tape from.  It featured a pair of British voices discussing their research on differences in men and women.  They tried to focus on relationships, but even that topic should probably take a couple lifetimes to properly research.  But they still managed to summarize the different perspectives in a relationship during the five minute clip.  The cliffs notes version, women like to communicate and have needs that most men find irrational whereas men often see the relationship in very concrete matters.  They dabbled in the historical/evolutionary forces that led men to be more like providers and protectors whereas women are family oriented, nurturing, etc.

Full disclosure.  I'm probably as clueless as the next guy when it comes to relationships with the opposite sex.  But this isn't a testimonial on my experiences or opinions regarding relationships.

Keep in mind that this was a club full of only men.  There was one female, the fiance of my current translator, but she doesn't speak English.  Everyone else was an XY.

The conversation focused on why women want shoes for the first half hour.  "Why do they like shoes?"  "Haitian women just wish they had the possibility to buy shoes."  And so on.  At some point they asked for my input.  I wanted to try and redirect them to get away from the concrete thinking of shoe-philia.  I pointed out that the title refers to perspectives about relationships.  Men don't have an idea of what it takes to be in a  relationship whereas women get worked up about stupid stuff like shoes.  I tried to get the focus on what a healthy relationship is.  Discuss the different needs for men and women.

It didn't happen.  But we did end up re-directing and talking about relationships instead of why people want to buy shoes.  We took a survey of how many men were in some sort of relationship.  Mike and I made up almost half.  My translator was with his girlfriend and two others were married.  No one else would claim a relationship.

The topic turned.  Suddenly we were talking about trust in a relationship.  The gentlemen were discussing what was an appropriate level of trust.  This ranged from, "I don't want to know what she's doing" to "I am always honest with her if she asks me where I am" to "I don't need her asking me a lot of questions."  These three did most of the talking.  One was married.  He made it clear that he should know where she is at all times and vice versa.  He said he often calls her just to see where she is and sometimes he will follow that call up with a random visit or talking to someone else in the same area.  He was perfectly comfortable if his wife would do the same.

The other two were far less forthcoming.  One was my former translator who had to resume his job as an English teacher.  He made it clear that in any relationship he had, he wanted boundaries.  He didn't want to have to tell his "girl" where he was going, who he was talking to, or what he was doing.  "Sometimes you are talking to a girl and she [his girlfriend] don't need to know about it.  You aren't doing anything more than talking, so you're fine."

The other gentleman, who clearly learned most of his English from America's hip hop culture, took the same stance from the opposite perspective.  He didn't want to know what his girl was doing.  If she was cheating on him he didn't want to know.  He was perfectly comfortable pretending that everything was going smoothly.

I truly wish I could have live tweeted the action from the conversation.  The insight into their culture was great for Mike and I.  From stories I had gathered that many relationships were male-dominated with the woman tending to the family at home.  Also, it seems like sex is less of a commitment than in our culture.  I don't know how they do it.  Up to ten people live in the same house with only one bed, yet people still find themselves pregnant.  I already discussed going to the ocean and maybe that's where everyone is.  I don't know.  I hope to take these last couple weeks to learn more about the local culture.  I have assumptions, but they aren't always correct.  I walked away from that meeting with more questions than answers.  But I did discover one thing, only one man in that group had a "clue" and he is currently set to be married in May.

Sèt

If you have been paying attention you would have realized that my previous "Number" posts were written in French.  That's because I've been too lazy to learn the Creole spelling.  I still don't know the Creole spelling for the numbers that I remember from high school, but I put forth enough effort to open a PDF file with them all listed.  FWIW I've been asked to help coordinate a group Creole class so we can all practice together in preparation for future trips.  More to come on that in a future post.  None of this has anything to do with the number '7'.  #RamblingAboutNothing  #CommentIfInterestedInLearningCreole

Have you ever been in a situation where you know that you're going to be punished for trying to be polite?  That seems to happen a lot in Haiti.  It could be the polite gesture of someone offering food out of their 'kwizin'.  I haven't found anyone who truly has an abundance of food like we know in America.  Most of the time they know exactly how much to make so that everyone they're trying to feed is satisfied.  Heck, they know how much they need to take to the market to buy that food.  Yet here they are offering it to a 'blan'.  Some times you have enough excuses ready to turn the food down.  But other times you suck it up and take a few bites knowing full well that your GI tract is going to retaliate.

The frequency of transmissible illnesses down here is crazy.  As a U.S. med student, I assumed I would get sick for a couple days on pediatrics.  Tons of kids are coming in with the crazy new batches of viruses that get passed around the grade schools and you can only be so diligent with hand-washing.  So I planned on one or two days of a cold-like illness.  Other than that, the U.S. is relatively devoid of communicable illnesses when compared to Haiti.  I just want to point out that I'm not including sexually transmitted infections in this discussion.  While sex is a large part of both cultures - In fact one of the CHWs asked me today why, "Haitian women enjoyed sex so much" - I do not plan on exploring or discussing the topic on a personal level.  

But the namesake of this post is scabies.  Otherwise known as the "Seven Year Itch."  And understandably so. This mite - highly contagious mite mind you - burrows under the skin and bites, claws and poops its way through different parts of your body.  The trail it leaves is fairly easy to spot.  And the creepy crawly sensation you feel after examining a patient with it is also diagnostic.  Kids do not know that this 'grate' is so contagious.  So, while I'm sitting there trying my hardest not to let my clothes touch him/her they still feel compelled to give me a hug after I've informed them that we can treat their rash.  Sweet.  To be fair, it takes way more than a hug to contract scabies.  But knowing that doesn't stop the creepy crawling sensation from sending shivers down my spine.  

In a U.S. carpool the greatest concern is someone letting loose a fart.  After having just spent all afternoon in a tap tap shared by 20 people - including one whom I was taking to a hospital for evaluation for probable tuberculosis - I found a whole new meaning to the phrase #SilentButDeadly.  By twenty people I mean that at its max the tap tap had 20 passengers crammed in the back or hanging on for dear life.  The total number of passengers served was well over 30 as many would get on for just a short distance.  That's a lot of exposure.  By comparison, if a patient is concerned to have tuberculosis the hospital goes into lock down mode.  They are immediately admitted into a negative pressure room and everyone has to have specially fitted masks in order to enter #TheyNeverTellTheMedStudentTheseThings.  Think back to the dude that hopped on the airplane for his honeymoon in Greece #BigNoNo.  He got in all sorts of trouble by all the public health gurus.  Why?  Because we care?  No.  Because we understand.  

We have the luxury of knowing how different diseases spread.  A large amount of that information is now considered common knowledge thanks to aggressive public health campaigning.  It took time and money, but people in the U.S. know that HIV is transmitted through contact with body fluids such as blood or semen.  In Haiti, it's "common knowledge" that if you have sex in the ocean that you cannot contract HIV.  And that's why there are so many couples at the beaches... #MakesMeRegretSwimming.  In the U.S. we trust in the Germ Theory and recognize that there are bacteria smaller than the naked eye can see that cause us to be sick.  In Haiti they attribute food and water borne illness to poison, curses, or dirt.  

This came to a head last Friday as Mike and I took the CHWs to a house where three of the family members had just been to our clinic complaining of a rash.  You guessed it.  Scabies.  I saw this as the perfect opportunity to get the CHWs out of the boring clinic/classroom setting and into the community where they belong.  We brought some chlorox and a scale for dosing Ivermectin.  We were going to de-scabie the entire house.  They didn't want it.  They wanted our medicine, sure, but they didn't want us to clean their clothes and sheets.  The family was skeptical.  And why shouldn't they be?  A couple of white dudes with their posse of Haitian ladies come and say they need to "clean the family's sheets."  Sounds like a curse or poison waiting to happen.  And so we left.  Seven people lived in that house.  At least five of them had signs/symptoms of scabies.  One of them was a two month old baby.  One was my sixty-year-old woman with probably TB that I tried to take to another hospital today.  And the rest were assorted family members.  All living under the same roof.  All sharing the same bed, comforter, sheets, etc  #MitesDontMakeGoodSnuggleBuddies.  

I predict that the CHWs will continue to struggle with trying to convince the community of the Germ Theory. To be fair, it took years for it to be generally accepted in our society.  First a doctor had to report that less women died when he washed his hands after cadaver lab before going to the obstetric unit.  And then someone else had to see the little bugs under a microscope.  From then on we caught fire with discovery after discovery.  But that happened in our country, discovered on our turf, was reported in our papers, and written in our language.  Haiti has no such connection to these scientific discoveries.  They have us.

Hydrocephalus

This post could have easily titled 'trente' as that might be the circumference of the little girl's head.

 Meet Vorline Charles.  She was born on 28-March-2007.  And unbeknownst to her, to her proud mother, and to her diligent father, she had something wrong anatomically with her brain.  The brain has its own fluid system.  Certain cells make the fluid.  It swims through special tunnels within the brain and surrounds the brain and spinal cord on the outside.  And then it is absorbed by other cells so that it doesn't build up.  But if there is a problem anywhere in that system, something like this occurs.  Hydrocephalus.

She's four now.  She doesn't walk.  But how could you with a head three times the size and weight of your body?  That's why it takes humans so long to walk in general - our disproportionate head size #TopHeavy. So when a disease makes that worse you can't expect her to walk at the same age.  Her language is not well developed.  You may be asking, "But it's Creole, how can you understand it anyways?"  Good point.  I can't.  But I asked the mom and she said that she isn't speaking like she should.


I first met Vorline while I was out on one of my community romps.  She was crawling on the ground and literally followed me, on the ground, to two houses.  Smiling the whole way.  I walk towards her, trying to match her smile, but as you can see by her picture it's impossible.  Her arms went up.  She wanted me to hold her.  I think I can handle picking up an adorable little kid.  She grabbed my sunglasses and tried to fit them on her head... #NotGonnaHappen.  But they did cover her eyes when I put them on her.

It's crazy when you're with this girl.  She truly enjoys life.  She's only had 4 years of it, and by most opinions she's had a pretty rough go, but she loves the hell out of life.  They should probably take record her laugh and use it in every movie from now till the end of time.  It's perfect.

And it makes me wonder what can we offer this girl with regards to treatment.  She'll likely need a shunt placed to help relieve the pressure causing her head to swell.  Depending on where the obstruction is in that path I described the shunt may need to pass through brain tissue.  I think everyone can imagine the potential for complications.  Death.  Loss of certain functions.  Change in personality.  But the bright side is that most kids with hydrocephalus after 1 year - which we think this kiddo fits that bill - usually live normal life spans.

We've been informed that at the children's hospital in Port-au-Prince that they have a neurosurgeon who does shunts.  Rigan, whom many of you know and many more I'm sure have heard of, is an employee within that system.  Our hopes are that he can help us bypass the lottery that they have setup to determine which patients are seen by the doctors that day.  Mom wants a normal baby.  I don't blame her.  But I can't say that I've found a happier baby in my time down here.  Nor another one who appreciates #GreatHair.

The Hex 2

Anyone who follows me on facebook may remember a status I had a while back.  In it I mentioned how we had spent $50 US to take two severely malnourished children to a hospital at Cazale (Cajale, I don’t know the spelling).  The organization there, Real Hope 4 Haiti, was started by a pair of American sisters back in 1998.  They had been traveling to Haiti with their mother, a nurse, since before they graduated high school.  When the time came, they each knew they wanted to move to Haiti permanently and have slowly built one of the nicest medical services I’ve seen in my time here.  The place is staffed almost entirely by Haitians.  They can provide treatment for HIV and tuberculosis.  And they have an inpatient unit that specializes in children with severe malnutrition.  I can’t even begin to send enough praise to this group.  But back to our story.

One child suffered so badly from protein malnourishment that her hands, feet and face were puffy, a sign of hypoalbuminemia.  She was two years old and could not support the weight of her own head.  She lay in her mother’s arms like a floppy rag doll.  I didn’t think there was any way we could help this child.

The other not only had malnutrition, but she also suffered from a skin disorder that caused the top layers of her skin to blister off.  I racked my brain for all the skin diseases that I have learned and forgotten umpteen times.  Is it epidermolysis bullosa, pellagra, pemphigous bulgaris, etc?  I don’t know.  But at the end of the day it honestly wouldn’t matter that much in Haiti. We weren’t going to do any genetic or protein testing.  It appeared to be a form that didn’t involve the mucous membranes and didn’t result in scarring after the blisters healed - all of which point to it being relatively tolerable when compared to the other similar skin disorders.

We took them each, by private tap tap, to the aforementioned hospital.  The staff was confident that the inpatient nutrition program would do wonders for them.

And they were right.  Every update we received told us that the babies were progressing very well.  They were soaking up all the calories they could.  The skin condition was improving with routine dressing care.  And then I got another email:

    The child that came with the skin condition.  The mom came and took her back home.  She first said we were not taking care of her well.  Then said that she wanted to take her to church so they could fast and pray for her.  I spent a long time with her explaining that this skin condition is not going to go away.  So she said it was not a malade dokte.  So that means she will not seek medical treatment but will do herb treatment or go to the voodoo peeps.

I wish I could say that this was uncommon, but that would be a lie.  Sometimes it’s because a family member told them that they should seek the traditional practices and other times it’s because they aren’t seeing the results they expect with modern medicine.  To be fair, people in the United States take similar approaches.  There are “traditional healers” all over the place.  They hide behind the guise of chiropractors and various other monikers.  The herbal supplement industry has a multi-billion dollar market.  At the end of the day, any time you approach somebody for “health-improving” treatments or medicines that haven’t been discussed in peer reviewed journals you’re participating in a form of “voodoo.”  Not in the literal sense obviously.  I’m assuming most people who read this don’t pay a religious figure to become possessed by some demon or saint and provide magical healing powers.  But a placebo is a placebo.

I was deflated to hear that this mother had abandoned modern medical management for her little girl.  I can’t even begin to imagine what it would be like to have to make that decision.  All she sees is this skin disease that the little girl has had her whole life.  And whatever we’re doing looks unconventional compared to what she’s used to seeing traditional practitioners use.  Our bandages are white and come in plastic.  Very unnatural.  At home the people use boiled leaves, grass, and mud.  Much more natural.  That’s what has made sense her whole life.  And that’s probably what her friends and family were telling her to adopt.  It’s unfortunate.  All we can do is hope that if the baby gets sick again that she’ll give us another chance.  

The Hex 1

It wasn't a patient.  It was an interview I conducted during my research study.  A very quiet female who almost whispered the answers to every question I had.  She was young.  But she had borne four children.  Unfortunately their fate was no better than what I've found to be an alarmingly high rate of Haitian children; they died before their first birthday.  The survey prompts me to probe into their cause of death - which no one ever knows.  "Do you know what caused them to die?"  "A curse."  She said it so matter of fact that I would've mistaken it for sarcasm in the states.  This was no laughing matter.

Dr. Farmer lies to us in his books.  Or at least the message that I picked up on in his books is that voodoo is relatively non-existent in Haiti. My experience has been quite the contrary.  The belief in the power and the practice of voodoo is commonplace. This is the first of what is likely to be multiple discussions on my experiences with the voodoo culture around Arcahaie.  But back to the interview.


My follow-up questions were no longer scripted.  They came from my innate curiosity to learn as much about the local culture as I could.  I know that I live in a compound surrounded by so called "voodoo temples."  I heard their drums as they celebrated their New Year during my second week.  This was not even the first interview or patient I'd had that referred to voodoo powers in either providing treatment or causing malady.

It was the crucifix around her neck.  It had to be.  A silver cross with the figure of Jesus Christ hanging on it lying next to this woman's heart.  The same heart that truly believed that the reason her children died were because someone paid a voodoo practitioner to put a curse on them.  There is a quote that states, "Haiti is 90% Christian [Catholic] and 100% voodoo."  I feel like this woman fit the bill perfectly.  But apparently so would 90% of the population.

With further probing two of her children had had diarrhea shortly before their passing.  Another did not live to see 1 month.  When most children are delivered at home with little to no pre-natal care, an untrained 'fam sage' seeing the delivery through, and then that same 'fam sage' cutting the cord with whatever he/she can find - razor blade, glass, rusty machete, salt, rocks, etc - it isn't surprising that the childhood mortality rate is as high as it is.  But she doesn't know this.  She only knows that the voodoo priests have power beyond her comprehension and people have told her that this includes the power to curse the living.  And there are many voodoo priests to choose from.

I continued with my interview careful not to let my curiosity show through in my questioning.  I was and am always afraid that when I break off into spontaneity that people will mistake my interest in the morbid as excitement for their strife.  Unfortunately it seems that the morbid is what separates our two cultures and the differences are what I'm striving to characterize.  I try to reiterate that my intentions are solely to become acquainted with the community so that our organization can provide more appropriate medical care.  However, I've encountered many skeptics.

In the final questions of my surveys I always give the respondents the opportunity to list three needs that they perceive for the community at large.  I've received a range of responses ranging from incredibly insightful to cliche to downright confusing.  For this madame one might expect the desire to have better control over the voodoo practitioners.  In a community that seems to take violent crime very seriously - as in vigilante justice involving a rope and accelerant seriously - one would think that someone who has been the victim of murder on four occasions would perceive that as a problem.  No.  It's accepted.  In fact, she responded that she would easily go to a voodoo practitioner to heal her if the local clinic could not provide the results she wanted.  I suppose that if they are powerful enough to take life then they are also powerful enough to preserve life.  All it takes is the right amount of money.

Like I said.  I've heard many accounts of voodoo practitioners treating illnesses and causing them.  I've heard people claim to be Christian but still believe in the power of the voodoo men.  One of my workers is the son of a voodoo priest.  His fathers temple is one of the larger ones in the area.  My randomization pattern has caused me to cross paths with many voodoo men.  I've also come to find out that nearly one in five houses has a "devil house" built along side of it.  No one occupies that building except the devil.  Needless to say, he doesn't need to be interviewed for our survey's purposes.

Macrosomia

In my first test of being an intern on call I failed miserably.  Yesterday evening I was just finishing up my previous blog post anticipating a quick call back home to Rachel and my parents, when Angie got the call.  It was a woman who only spoke Creole.  Not helpful.  And kinda odd since Angie hadn't given her number out to anyone aside from our translators.  The only words we could make out were a frantic "M' maladi".  "M' veni".  It's only9 o'clock, but already it's pitch black out.  Great...

She calls back.  Still frantic.  Still parle-ing some gibberish that I can't comprehend.  "M' pa konprann."  I say that a lot around here.  We pass the phone to one of the girls so they can attempt to translate the message to us.  The patient is at Carrefou Poi (Literally 'Crossroads Beans').  She's pregnant and is experiencing a lot of pain.  Oh, by the way, apparently Guireline gave the patient Dr. Angie's phone number.  #NotHelpful.

She was not a new patient.  She had come to our clinic for routine obstetric care.  Based entirely on LMP she should have delivered on Monday of this past week.  Just like a baby not to come when it's convenient or expected.  The patient was getting a moto to drive her up here.  Definitely not the safest way to relocate a laboring woman.

We wait.  I have my headlight on and wheelchair at the ready down by the gate.  Angie prepares the procedure room for what appears to be another delivery.  I can't even hide my tiredness as I sit on the gate and yawn.  Fifteen minutes pass and still no sign of the patient.  One of the girls calls her back.  The moto broke down and she was in the process of walking up here.  Ugh.  I run get my phone.  Thankfully a number of moto drivers have given me their numbers because they like charging me twice what they charge a Haitian.  We call one and have one of the girls describe what's going on.  He accepts the job.

Another eternity seems to pass before we finally see the lone headlight making its way up the road.  The patient dismounts and I hand the driver 10 Haitian dollars.  It seemed appropriate given the circumstances.

The patient foregoes the wheelchair and hikes it up our long driveway to the procedure room.  She's a big girl.  The baby will be big, but this is her second child so hopefully it'll go smoothly.  We try and get her comfortable on the bed before we examine her.  She's 100 percent effaced and dilated to 3 cm.  She reports that she has not broke water yet.  Angie tells the patient that there is still plenty of time to go to the hospital if she wants, but that it's her decision.  The translator, however, puts her own little spin on it (paraphrasing), "You need to go to the hospital to deliver this child."  Luckily I know just enough vocab to catch when translators are missing key words.  This certainly wasn't the first time this 'translator' tried to discourage patients from coming here without our approval.  And this has been a point of frustration with her since we've figured it out.

The translator reports that "she will go to the hospital."  I very directly tell the translator to tell her that if she would rather deliver here that she can, but we can help you get to the hospital.  She needs to make the choice.  Ah, the patient wants to stay here to deliver.  #ThoughtSo #ScoreOneForKnowingJustEnoughCreole  #IWishSheWouldHaveGoneToTheHospital

She walks, a lot.  She doesn't even pause for contractions.  Just keeps plodding along.  She sounds pretty miserable.  Minutes turn into hours.  Unfortunately battle fatigue has led me to becoming rather cynical.  In a cruel bit of humor I decide to make a playlist to "encourage" her to deliver her baby.  The songs ranged from Justin Bieber's "Baby to Vanilla Ice's "Ice, Ice Baby" to "Baby, It's Cold Outside."  The irony was not lost on Dr. Angie or myself.  I even had a couple friends wisely suggest I add Salt-N-Pepa's "Push It."  Great decision.  Didn't seem to help.  The playlist went from 47 minutes to over 2 hours.

Midnight came and went.  I know this because I added Eric Clapton's "After Midnight".  Her water still hasn't broken.  Better add some songs calling for water.  Brad Paisley made two appearances, one with "Water" and the other with "Don't Drink the Water."  TLC's "Waterfalls" and The Temptations "I Wish It Would Rain" were a couple other late additions.  It wasn't until Led Lepplin's "When The Levee Breaks" that she finally came in.  Her water had broke.

Sweet.  She was  a multip.  The delivery should go smoothly from here on out.  Angie does a quick exam.  Butt.  The baby is breach.  Damn.  This won't be as easy as we thought.  We gameplan.  Our primary concern is going to be the mother.  We're going to try and avoid a cesarean because we are not equipped to stop any hemorrhage.  That's our only option at this point.

Her contractions are more frequent.  Her prayers become louder.  The baby is still riding high.  She's near complete dilatation.  We have her give some pushes with her next contraction to try and speed things along.  Two a.m. comes and goes and she hasn't progressed.  She's getting tired.  So are we.  Angie and I keep nodding off while we're sitting and waiting.  Her family is asleep in chairs in the room next door.

Dr. Angie performs another check.  Wait a minute.  We grab a speculum and look.  It looks like there is another amniotic sac.  We pierce it with a scalpel and fluid gushes out.  Sure enough, she hadn't broken her water.  Another manual exam.  Head!  It's the baby's head!  It's large but it's lined up the right way.  The bag that we thought had ruptured just distorted the previous exams enough to convince us the baby was breech. Of course, we were probably assuming the worst to begin with since that's what we've grown accustomed to.

She continues to contract and continues to shout for Jesus to make this stop.  At four o'clock the decision is made to take her to the hospital when dawn breaks.  The fetus needs to be evaluated just to make sure everything is going okay.  She's exhausted and her contractions are weaker and less frequent.

By this time I feel downright awful.  My stomach hadn't been sitting right for most of the day.  I am not sure if it was the eggs at lunch or the bean sauce and rice that I had tried Thursday while I was out in the community.  Seeing this woman labor for nearly 10 hours wasn't helping matters.  No anesthesia.  No pain killers.  No IV fluids.  Just her walking around with a baby trying to come out.  Glad I never have to do that.  I've always had respect for the childbirth process, but I still can't understand why women would want to go through with it.  I can't handle any more.  She's not progressing and I have already dry-heaved outside a couple times.  I give up and go to bed.  I was probably 45 minutes shy of 24 hours straight.  Guess I'm not ready to be a resident yet.  Dr. Angie soldiered on.

Morning dawned.  There was still no baby.  Her contractions had all but ceased at this point and the patient was exhausted physically and mentally.  We called for transportation to take her to the hospital.  We sent one of the girls to travel with the expecting mom and her sister.  Fortunately our CHW had had a full night's sleep.  Dr. Angie also received a bit more history before the patient departed.  Her first child was premature, by a lot.  She had had a miscarriage.  That explains the "quick delivery."  Unfortunately she failed to mention those key details.  Not that it would have changed our management much more, but we would not have been anticipating a relatively easy delivery had we known.

She got to the hospital.  We didn't have to pay a nurse $30 for her to stay and she didn't get sent to Port-au-Prince for some mysterious cholera.  She was seen, examined, ultrasounded, and eventually delivered a healthy baby without surgery.  They had to have given her some pitocin to encourage contractions, but I am still amazed that she did not go to section.

This was an interesting story, I thought, because the patient specifically requested that we handle the delivery.  She assumed that by us being 'blan' that we'd be better equipped to guide her through a smooth, painless, quick childbirth.  Maybe in the U.S., but not in Haiti where we only have 1 more liter of normal saline, no cord clamps, no pitocin and no anesthesia.  She ended up being much better off at the hospital.  Certainly the culture around here will never change.  I would guess that 80% of deliveries happen at home and that's totally fine.  The hospital couldn't handle all of them.  But what I do hope is that by her having a successful delivery that we've somewhat aided in restoring one family's faith in the local hospital and system. That would be a victory rivaling holding a brand new, healthy baby girl in my opinion.

Vingt-Deux Revisited

I haven't spoken much about the other girls living on the compound with Dr. Angie and I.  There was no particular reason for their exclusion other than it just didn't fit with the theme I've been rolling with.  However, today seemed like the perfect day to tell you all about one of them.

Meet Caroline (Kerline)

Today was her 22nd birthday.  #BonFet #DontKnowHowToMakeThoseLittleAccentSigns  Caroline lives and 'works' at the same compound I'm staying.  She is one of the students in Dr. Angie's community health worker class and was with us throughout the entire delivery discussed in the 'Mouri' post.  She's gonna be a good one.

I've admittedly never taken the time to ask about Caroline's past.  She speaks very little English.  M' parle Creole ti mal, though we all try and learn what we can from one another.  I know that she's very sweet.  And that she and the other girls can have outbursts where they act like giddy teenage girls.  She had never had pizza before Dr. Angie came down.  She had never had a cake before Dr. Angie came down.  And she had never had a s'more before I came down #WishingIHad'TheSandlot'OnMyComputer.  It was awesome to see her and the others react to their first taste of each of these.  She was actually terrified of the fire-roasted marshmallow.

 Caroline has many of the same complaints as any other girl you'd meet in the states.  She approached a few of us 'doctors' concerned about acne - is being an American contagious?  She has the same problem with cramps that takes her out of clinic every once in a while.  She loves Celine Dion.  She has the dogs and the goats trained to take the food out of her hand.  This is what I've seen from her.  The new tastes, words, sights and sounds that Dr. Angie and I have introduced her and the other girls have certainly been reason to make a joyful noise.  It's the life that she's lived up to this point that is likely less joyful.

She does not have a family.  I do not know if they passed away or if she was placed in an orphanage.  Orphanages in Haiti are not for children whose parents were killed.  They're for children that the parents cannot or will not take care of.  See post 'Fertility'.  She has three years to go before she finishes high school, something she definitely wants to do.  She battles depression.  She has periods where she just appears sad and distant.  Again, the language barrier and my allergy to emotion keeps me from probing.  But I wonder if there is more to her story.

One thing is for certain.  Raymond and Mahalia, the owners and operators of this mission, have truly done a wonderful thing by bringing her out of the city and offering her a home.  She must do chores, yes, and sometimes it can be unsettling to watch the blatant segregation of the 'workers' and us.  But she is free.  She is earning money that she doesn't even know about.  She is learning about her faith.  And her songs get to be heard by beleaguered white people.  

Needless to say, having her on the compound has been a blessing.  We've enjoyed having Caroline and her companion around so much that Dr. Angie has considered bringing the two girls to the United States over the summer.  Talk about an experience worth blogging about!

Atresia

There is one, and only one, purpose for me writing this post: to provide some positive pr for CHI.  While conducting my surveys earlier this week, I had a pair of mothers bring their children to me with medical complaints.  This happens fairly often.  I never turn them down, but most of the time I only decide between immediate treatment, referral to our CHW clinic, or referral to our large clinic in April/May.  Sure makes my job easier and nobody ever is let down.

These two ladies were carrying their children.  The first one had been having a "feyev" and loss of appetite for the last few days.  She was small.  Her belly was swollen.  "Has she had any diarrhea?"  "Yes."  I measure a mid-upper arm circumference.  It's borderline yellow and green.  Certainly not an emergency, but she's far from healthy.  I don't even hesitate.  "You should come to our clinic tomorrow morning.  We can give your baby some medicine to treat some of the infection in her stomach."  And it won't hurt to go ahead and establish this family as patients so we can follow up with the little girl #DontLetHerGetWorse.  Next Patient.

She's maybe a couple months old.  Her eyes fixate on nothing.  They just have a glassed appearance as they dart from left and right.  She doesn't even seem to localize to sound.  I'll have to review my developmental milestones later #MedStudentProblems #Step2Sucks.  I ask the mom what the problem is.  The answer is not one that I expected.  "She has no butt hole and she has poop coming out of her vagina."  Wow.  I didn't even have to ask.  All of a sudden the mom was sitting down, laying her child face down over her knee, and pulling down her pants.  Sure enough, no hole.  Just skin.

The fact that poop was coming out of her vagina was life-saving.  A quick Wiki search revealed that 1 in 5000 live births have this problem known as imperforate anus or anal atresia.  This sort of anomaly is diagnosed at delivery in the United States.  Meaning that the surgery is performed before the mom and baby leave the hospital.  This girl was born in mid-December.  Again, my role at the time was simply triage.  "You need to bring her to our clinic tomorrow morning" #BrokenRecord.  "She'll likely need surgery and we can help you figure out where you need to go."  Needless to say, she needed screening for a number of other congenital abnormalities.  Those things run in packs. #VACTERL

I went about the rest of my day #MoSurveysMoProblems.

The next morning clinic went surprisingly well.  Angie ended up seeing both the patients and gave me the quick update when I got back for dinner that evening.  One got Cipro for dysentery.  The other got a phone call to our local contacts to figure out how to get her surgery.  The gist was this, they could do the surgery at the children's hospital  in Port-au-Prince.  In order to be seen you have to show up well before 7 am when they start handing out cards.  If you get a card then you'll be seen that day.  If you do not then you're out of luck.  As far as we know there is no triage.  There is merely chance.  We gave the patient some money and told her the process.

Later that same day we talk to some other people.  The surgery is certainly performed in Haiti, but to terrible outcomes.  Most children do not survive.  Not much else needed to be said after that.  The mice wheels were rolling.  Angie emailed Dr. Chris Cooper at Iowa about our situation.  The Dean was nice enough to forward the girl's story on to the surgery department.  Within an hour we had a surgeon volunteer to fly to Haiti to do the procedure, or we could bring the girl to him.  #Success.

All we have to do now is file for a medical visa, convince the University of Iowa to accept her as a patient, fly her to the United States, have the surgery go swimmingly, and then fly her back to Haiti.  We're no Dr. Paul Farmer.  We have neither his connections nor the financing of a well-endowed private University supporting us.  I would copy/paste the instructions that were sent to us on here, but it would make my already long winded blog posts creep into the ad nauseum range.  Let's just say it asks for many things including many identifying paperwork that I would be very surprised if the family had.

If only the paperwork were the major hurdle.  The University of Iowa is a publicly funded academic medical center.  Therefore, the decision-makers must decide how to spend tax-payer money.  I have encountered this problem before when I pursued having them donate expired medical supplies to our organization for use in Haiti.  Let's be honest, does sealed IV tubing really have an expiration date?  Of course not.  Even medication is okay for some time after the expiration date.  It may not be quite as effective, but few will convert to harmful substances.  However, the hospital has to unload the supplies.  Why not give them to a charitable organization who will still make good use of them?  Because it's publicly funded.  Every piece of medical equipment in the hospital was purchased with public funds.  Therefore, each piece of equipment must be accounted for, even if it is 'accounted for' in the trash bin.  #Poppycock.

I was naturally frustrated by the entire process, and our current endeavor will likely lead to similar frustrations.  I would like to think that some common sense things should be allowed, like donating medical supplies when it would otherwise be thrown away.  Shouldering the costs of a major surgery and the possibilities of a prolonged hospital stay are definitely more difficult decisions.  On the one hand you have the #HumanFactor.  Anyone who can look at this little girl in her roving eyes and deny her a surgery is a heartless SOB.  Fact.  Unfortunately, we have to keep our decision makers away from emotion so that they can make the most reasonable decisions based on objective information.  I'm sure when one insurance company gets persuaded to suddenly cover a major experimental treatment that every other insurance agency shudders.  It's bad for business.  You can't let emotion get in the way.

Sometimes I get like that.  I try and separate myself from the #HumanFactor and think big picture.  In the big picture, is it a good idea to expend the thousands of dollars to fly this child to the U.S. for her surgery?  I don't know.  Is this a good precedent to set?  Should we tell the people of Arcahaie that we don't think the Haitian doctors are capable of taking care of you, so we'll just ship you to Iowa so we can take care of you?  But then I realize that I'm the 'doctor' (or one Oto rotation and a semester's tuition shy of being one) and I can't ignore that #HumanFactor.  I have to see that baby.  I have to look her in the eyes.  I have enough problems sleeping at night (See Insomnia) that I don't need to have pervasive thoughts reminding me I didn't do everything I could to save this girl's life.  And trust me, they would be screaming in my head.  #VitaminH couldn't even stop them.

I think the #HumanFactor that I refer to is the most important thing for doctors.  The first law of medicine is 'do no harm'.  If physicians cared.  Really cared.  Then that would go without saying.  If you care about your patient you will not harm them.  If you care about your patient you will advocate for them.  If you care about your patient they will trust and care about you.  If you care about your patient you run the risk of getting hurt.  So, many doctors stop caring.  It's the easy way out.  Patients like this one are reminders that I can't take the easy way out.  She deserves an advocate.  She deserves to be cared for.  I'm a doctor.  That's my job.

I cannot predict what will happen for this girl, her family, and, most importantly, her anus.  I only want a successful surgery followed by an uncomplicated and complete recovery.  I don't think about cost.  I can't think about cost.  I can only think about how I can help this girl.  I'll understand if the University of Iowa does not want to assume the liability of her case.  I won't accept that we can't help her.  She is our patient now, Angie's and mine.  And we care.

I'll do my best to continue to post updates about the progress in getting her treatment.  And if anyone feels inclined to share this story with some influential political leaders that might end up falling for the story, I am supportive.